Healthcare Provider Details

I. General information

NPI: 1841639994
Provider Name (Legal Business Name): MRS. CAROL ANN VESTAL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2013
Last Update Date: 06/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

518 MEADOW RD
RUSSELLVILLE AR
72802-1829
US

IV. Provider business mailing address

PO BOX 1420
DANVILLE AR
72833-1420
US

V. Phone/Fax

Practice location:
  • Phone: 479-495-5444
  • Fax: 479-495-5446
Mailing address:
  • Phone: 479-495-5444
  • Fax: 479-495-5446

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number7046
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: